Recognition and Assessment of Anxiety & Depression in Early Childhood

ANXIETY AND DEPRESSION Recognition and Assessment of Anxiety & Depression in Early Childhood Nicholas D. Mian, MA, Alice S. Carter, PhD University of Massachusetts Boston, Department of Psychology, USA March 2013 Introduction Anxiety disorders are characterized by emotional arousal associated with fear, worry, or nervousness that is out of proportion to the situation. Significant fears in preschool-aged children have been documented since the 1920s, 1 but only recently have anxiety disorders in early childhood been widely recognized as impairing and deserving of specialized treatment. Young children s anxiety often manifests as fearfulness, defiance or tearful outbursts in stressful situations (e.g., separating from a caregiver). Diagnosis of depression in early childhood remains controversial, but symptoms seen in older children, including sadness, appetite/weight problems, sleep problems, low energy and low self-esteem can represent a distinct syndrome in young children. 2 To meet diagnostic criteria, symptoms must be severe enough to impair normal functioning. Most young children with depressive symptoms do not meet criteria for a DSM-IV diagnosis, but experts agree that children can experience the core symptoms of depression by age 3. 2 In psychopathology research, assessment is designed to capture psychological phenomena to deepen understanding of disorder presentation, course, risk factors and treatments. Assessment in a clinical context refers to gathering screening and/or clinical data to inform clinical judgments regarding the diagnostic presentation of a specific child and to tailor individualized interventions to promote optimal social, academic and family functioning. The key to valid, reliable assessment is employing a multi-method, multi-informant approach that includes repeated clinical observations, diagnostic interview, developmental history, and standardized, comprehensive symptom checklists. 3 Subject Few studies have closely studied the prevalence of psychiatric disorders in preschool-aged children. Research from the United States reported prevalence rates as high as 9% for anxiety disorders and 2% for depression 2013-2017 CEECD / SKC-ECD ANXIETY AND DEPRESSION 1

among preschool children. 4 A recent study in Scandinavia also found 2% of children to be affected by depression, but rates for anxiety disorders were much lower (1.5%). 5 While most childhood fears and transient sadness are normative, some children suffer from emotional problems that cause significant distress and impairment, limiting their ability to develop age-appropriate social and pre-academic skills and/or participate in age-appropriate activities and settings. Assessment is necessary to understand the phenomenology of emotional symptoms and identify young children in need, which is paramount to connecting them with ameliorative services. Problems Researchers struggle to distinguish variations in temperament, (stable individual differences relating to reactivity and self-regulation), from symptoms of psychopathology. There is also inconsistency regarding studying anxiety and depressive symptoms as a single internalizing domain or as two clinically-distinct presentations. 6,7 Similar issues with how to classify symptoms are reflected in the lack of consensus as to whether emotional problems should be conceptualized and studied in a categorical versus dimensional fashion. 8 Diagnostic criteria (DSM-IV-TR) 9 are often inappropriate for young children and do not capture developmentallysalient types of impairment (e.g., disruption in family routine), which make it difficult to apply psychiatric research methods. Despite significant advances in the assessment, recognition and treatment of early childhood emotional disorders, 10-12 rates of mental health service receipt and participation in prevention programs remain low, especially for ethnic minority children and those living in poverty. 13-16 Research Context Several widely-used parent-report checklist-style assessments (e.g., Child Behavior Checklist, 17 Infant-Toddler Social and Emotional Assessment, 18 Behavior Assessment System for Children 19 ) cover a broad range of functioning, including internalizing, externalizing and other problematic behaviours in early childhood. Other methods include the Preschool Age Psychiatric Assessment, 20 a structured diagnostic parent interview, and laboratory observation. Young children are often unable to describe their own emotional experiences using traditional methods. Hence, the Berkeley Puppet Interview uses child-friendly puppets to help preschool-aged children identify symptoms. 21 One novel assessment, the Picture Anxiety Test, uses pictures to aid young child report of anxiety. 22 Advancing the study of emotional assessment in young children necessitates a conceptual distinction between temperament and internalizing symptomology. For example, behavioural inhibition (prominent shyness in novel and social situations 23 ) has long been considered a normative temperamental profile that increases risk for developing an anxiety disorder later in childhood, 24 but for some children may represent an early onset of disorder. 10,25 Unfortunately, most assessments do not capture child or family impairment, which is one way to distinguish between these constructs. Evidence suggests that anxiety and depressive symptoms are correlated but distinct entities, 26 although they are seldom studied separately in young children. Whereas emotional symptoms reflect biological processes and mechanisms, there currently exists no biological test. Some psychophysiological assessments (galvanic skin response, heart rate, breathing, pupil dilation, stress cortisol) can identify anxiety-related patterns of autonomic arousal, but a clinical diagnosis still requires diagnostic interview to assess symptom onset, duration, severity 2013-2017 CEECD / SKC-ECD ANXIETY AND DEPRESSION 2

and associated impairment. Finally, emotional symptoms tend to be relatively stable throughout childhood if untreated. 27,28 Key Research Questions 1. How can assessment methods be improved to minimize reliance on parent report, while still remaining minimally labor-intensive? 2. How can assessments differentiate between temperament and clinically-significant emotional symptoms? 3. What criteria should be used to diagnose anxiety and depressive disorders in young children, or would employing a dimensional approach be advantageous? 4. How can awareness and recognition be improved to increase participation in prevention and early intervention efforts? Recent Research Results Significant advances have been made in assessment methods and age-appropriate diagnostic criteria for emotional disorders in young children. 29-31 Differentiation between symptoms of individual anxiety disorders (e.g., separation anxiety, generalized anxiety) has been found as early as two years of age. 6 One novel assessment tool for children aged 3-5, the Preschool Anxiety Scale Revised, captures these various dimensions of anxiety symptoms. 32 In addition, attentional bias to threat has been identified as a possible candidate for assessment of risk for anxiety disorders. 33 Regarding depression, novel findings underscore the validity of preschool diagnoses, as well as potential targets for assessments. For example functional magnetic resonance imaging (fmri), children with a history of preschool-onset depression demonstrated distinct patterns of brain activation, which were similar to those of adults with depression. 34 Other research documents that DSM-IV criteria for depression do not adequately capture the disorder's course in preschool-aged children. 35 Similar to the heightened awareness regarding preschool depression, evidence suggests that young children can also suffer from post-traumatic stress disorder when age-adjusted diagnostic criteria are employed. 36 Research Gaps More research is needed to fully understand the phenomenology and diagnostic presentation of emotional disorders in young children. This is especially true for depression, which is often difficult to differentiate from behavioural disorders since both are characterized by elevated irritability and reactivity. More research is needed to improve integration of data from observational systems, clinical interviews, child-report assessments and measures of child and family impairment. Research that identifies meaningful ways of distinguishing between temperament and clinically -significant emotional symptoms is also needed. Finally, research is needed on best practices for increasing awareness of clinically significant emotional disturbances in young children to better engage parents, pediatricians and educators in early identification, prevention and intervention efforts. 2013-2017 CEECD / SKC-ECD ANXIETY AND DEPRESSION 3

Conclusions Recent advances in assessment methods have made it clear that young children can suffer from serious emotional disorders. These disorders are distressing and impairing to young children and their families and present similarly to disorders in older children. Advancements have led to improved assessment methods (i.e., diagnostic interviews, observational systems, child-report assessments, psychophysiological tests) that reduce sole reliance on parent reports and increase diagnostic validity and reliability. Methods for improving the developmental appropriateness of diagnostic criteria for emotional disorders have also been proposed. While these advances mark substantial progress, more research is needed. A lack of consensus remains on the boundary between temperamental variation in emotional reactivity and emotional psychopathology and how to differentiate these constructs. Despite availability, screening tools for identifying young children at risk are underutilized, partly due to limited awareness among pediatricians, parents and educators. Even when identified, rates of parent participation in clinical services, including prevention efforts, remain low. Implications for Parents, Services and Policy The lack of awareness regarding the importance of identifying and ameliorating young children s emotional disturbances is one of the greatest challenges facing advances in assessment and identification of early childhood emotional problems. This problem is manifested by low levels of treatment-seeking behaviour by parents, 14 as well as the rarity of referrals from pediatricians and early educators. Compared with externalizing problems, such as aggression, emotional symptoms tend to be more difficult to recognize and assess, and because they are less disruptive, they are less likely to get noticed. However, it is clear that young children can struggle with distressing and impairing emotional problems that warrant sophisticated assessment and treatment approaches. Emotional disorders interfere with important aspects of development by reducing exposure to challenging situations that are essential for social development and learning. With this in mind, researchers continue to refine assessments and screening measures to identify young children in need of services, but dissemination and broad systems for implementation are still developing. References 1. Freud S. Analysis of a phobia in a five-year-old boy (little Hans). Revue Francaise de Psychanalyse. 1928;2, 3. 2. Luby JL, Belden AC, eds. Mood disorders: Phenomenology and a developmental emotion reactivity model. In: Luby JL, ed. Handbook of preschool mental health: Development, disorders, and treatment. New York, NY US: Guilford Press; 2006. 3. DelCarmen-Wiggins R, Carter A. Handbook of infant, toddler, and preschool mental health assessment. New York, NY US: Oxford University Press; 2004. 4. Egger HL, Angold A. Common emotional and behavioral disorders in preschool children: Presentation, nosology, and epidemiology. Journal of Child Psychology and Psychiatry. 03 2006;47(3):313-337. 5. Wichstrøm L, Berg?Nielsen TS, Angold A, Egger HL, Solheim E, Sveen TH. Prevalence of psychiatric disorders in preschoolers. Journal of Child Psychology and Psychiatry. 2012;53(6):695-705. 6. Mian ND, Godoy L, Briggs-Gowan MJ, Carter AS. Patterns of anxiety symptoms in toddlers and preschool-age children: Evidence of early differentiation. Journal of Anxiety Disorders. 2012;26(1):102-110. 7. Eley TC, Stevenson J. Using genetic analyses to clarify the distinction between depressive and anxious symptoms in children. Journal of Abnormal Child Psychology. 04 1999;27(2):105-114. 8. Brown TA, Barlow DH. Dimensional versus categorical classification of mental disorders in the fifth edition of the Diagnostic and statistical manual of mental disorders and beyond: Comment on the special section. Journal of Abnormal Psychology. 11 2005;114(4):551-556. 9. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. text revision, 4th ed. Washington, DC: American 2013-2017 CEECD / SKC-ECD ANXIETY AND DEPRESSION 4

Psychiatric Association; 2000. 10. Kennedy SJ, Rapee RM, Edwards SL. A selective intervention program for inhibited preschool-aged children of parents with an anxiety disorder: Effects on current anxiety disorders and temperament. Journal of the American Academy of Child & Adolescent Psychiatry. 06 2009;48(6):602-609. 11. Hirshfeld-Becker DR, Masek B, Henin A, et al. Cognitive behavioral therapy for 4- to 7-year-old children with anxiety disorders: A randomized clinical trial. Journal of Consulting and Clinical Psychology. 08 2010;78(4):498-510. 12. Luby J, Lenze S, Tillman R. A novel early intervention for preschool depression: Findings from a pilot randomized controlled trial. Journal of Child Psychology and Psychiatry. 2012;53(3):313-322. 13. Swanson ME, Wall S, Kisker E, Peterson C. Health disparities in low-income families with infants and toddlers: Needs and challenges related to disability. Journal of Child Health Care. 2011;15(1):25-38. 14. Kataoka SH, Zhang L, Wells KB. Unmet need for mental health care among U.S. children: Variation by ethnicity and insurance status. The American Journal of Psychiatry. 09 2002;159(9):1548-1555. 15. Bjørknes R, Jakobsen R, Nærde A. Recruiting ethnic minority groups to evidence-based parent training. Who will come and how? Children and Youth Services Review. 2011;33(2):351-357. 16. Godoy L, Carter AS. Identifying and addressing mental health risks and problems in primary care pediatric settings: A model to promote developmental and cultural competence. American Journal of Orthopsychiatry. in press. 17. Achenbach TM, Rescorla LA. Manual for the ASEBA preschool forms and profiles. Burlington, VT: University of Vermont, Department of Psychiatry; 2000. 18. Carter AS, Briggs-Gowan MJ. ITSEA Infant-Toddler Social and Emotional Assessment. San Antonio, TX: Psychological Corporation Harcourt Press; 2006. 19. Reynolds CR, Kamphaus RW. Behavior Assessment System for Children-Second Edition (BASC-2). Circle Pines, MN: AGS; 2004. 20. Egger HL, Angold A. The Preschool Age Psychiatric Assessment (PAPA): A Structured Parent Interview for Diagnosing Psychiatric Disorders in Preschool Children. In: DelCarmen-Wiggins R, Carter A, eds. Handbook of infant, toddler, and preschool mental health assessment. New York, NY US: Oxford University Press; 2004:223-243. 21. Measelle JR, Ablow JC, Cowan PA, Cowan CP. Assessing young children's views of their academic, social, and emotional lives: An evaluation of the self-perception scales of the Berkeley Puppet Interview. Child Development. 12 1998;69(6):1556-1576. 22. Dubi K, Schneider S. The Picture Anxiety Test (PAT): A new pictorial assessment of anxiety symptoms in young children. Journal of Anxiety Disorders. 12 2009;23(8):1148-1157. 23. Kagan J. Behavioral inhibition to the unfamiliar. Child Development. 12 1984;55(6):2212-2225. 24. Kagan J, Snidman N. Early childhood predictors of adult anxiety disorders. Biological Psychiatry. 12 1999;46(11):1536-1541. 25. Egger HL, Angold A. Anxiety Disorders. In: Luby JL, ed. Handbook of preschool mental health: Development, disorders, and treatment. New York, NY US: Guilford Press; 2006:137-164. 26. Godoy L, Carter AS, Wagmiller RL, et al. Modeling of internalizing subdomains from ages one to three years. Paper presented at: the annual meeting of the American Psychological Association. 2008; Boston, MA. 27. Bosquet M, Egeland B. The development and maintenance of anxiety symptoms from infancy through adolescence in a longitudinal sample. Development and Psychopathology. 03 2006;18(2):517-550. 28. Luby JL, Todd RD, Geller B. Outcome of depressive syndromes: Infancy to adolescence. In: Shulman KI, Tohen M, Kutcher SP, eds. Mood disorders across the life span. New York, NY, US: Wiley-Liss; 1996:83-100. 29. Luby JL. Affective Disorders. In: DelCarmen-Wiggins R, Carter A, eds. Handbook of infant, toddler, and preschool mental health assessment. New York, NY US: Oxford University Press; 2004:337-353. 30. Scheeringa MS, Zeanah CH, Myers L, Putnam FW. New findings on alternative criteria for PTSD in preschool children. Journal of the American Academy of Child & Adolescent Psychiatry. 05 2003;42(5):561-570. 31. Zero to Three. DC:0-3R: Diagnostic classification of mental health and developmental disorders of infancy and early childhood(rev. ed.). Washington, DC US: Zero to Three/National Center for Infants, Toddlers and Families; 2005. 32. Edwards SL, Rapee RM, Kennedy SJ, Spence SH. The assessment of anxiety symptoms in preschool-aged children: The revised Preschool Anxiety Scale. Journal of Clinical Child and Adolescent Psychology. 2010;39(3):400-409. 33. Fox NA, Pine DS. Temperament and the emergence of anxiety disorders. Journal of the American Academy of Child & Adolescent Psychiatry. 2012;51(2):125-128. 2013-2017 CEECD / SKC-ECD ANXIETY AND DEPRESSION 5

34. Barch DM, Gaffrey MS, Botteron KN, Belden AC, Luby JL. Functional brain activation to emotionally valenced faces in school-aged children with a history of preschool-onset major depression. Biological Psychiatry. 2012. 35. Gaffrey MS, Belden AC, Luby JL. The 2-week duration criterion and severity and course of early childhood depression: Implications for nosology. Journal of Affective Disorders. 2011;133(3):537-545. 36. Scheeringa MS. Developmental considerations for diagnosing PTSD and acute stress disorder in preschool and school-age children. The American Journal of Psychiatry. 2008;165(10):1237-1239. 2013-2017 CEECD / SKC-ECD ANXIETY AND DEPRESSION 6